İhmal edilmiş yetişkin çarpık ayak deformitesinin tedavisinde tek seansta yapılan üçlü artrodez ve posteromedial gevşetmenin orta dönem sonuçları

Abstract

Amaç: İhmal edilmiş çarpık ayak deformitelerinde aynı seansta uygulanan posteromedial gevşetme ve üçlü artrodezin orta dönem sonuçlarını literatür eşliğinde değerlendirmek.

Çalışma planı: On bir hastanın (4 kadın, 7 erkek; ortalama yaş 26, dağılım [15–50]) 15 ayağına aynı seansta posteromediyal gevşetme ve üçlü artrodez uygulandı. Tüm hastalara U çivisi ile internal fiksasyon yapıldı. Klinik değerlendirmede AOFAS (American Orthopaedic Foot and Ankle Society) tarafından tanımlanan ayak bileği-ard ayak klinik skorlaması kullanıldı. Radyolojik değerlendirme, ön arka ve yan çekilen grafiler üzerinde talokalkaneal ile talus-1.metatars açılarının ölçümleri ile yapıldı. Ortalama izlem 7.5 yıldı (dağılım, 6–11).

Bulgular: Ameliyat öncesi ortalama 39 (dağılım, 15–52) olan AOFAS skoru, son değerlendirmede 88 (dağılım, 76–94) olarak bulundu (p<0.0001). AOFAS skorlaması ile birlikte fonksiyonel ve kozmetik değerlendirmeler göz önüne alındığında sonuçlar, 15 ayağın dokuzunda çok iyi, beşinde iyi ve birinde orta olarak bulundu. Son kontrollerde radyolojik değerlerin normal fizyolojik sınırlarda olduğu görüldü. Ameliyat öncesi ile ameliyat sonrası arasında anlamlı klinik ve radyolojik düzelme elde edildi. Ortalama kaynama zamanı 12.4 (dağılım 7–36) hafta idi. Psödoartroza hiçbir hastada rastlanmazken iki hastada kaynama gecikmesi, bir hastada da talusta avasküler nekroz gelişti. Ameliyat öncesi dönemde hastaların beşinde ayakbileğinde değişik derecelerde dejeneratif değişiklikler vardı. Son kontrollerde dokuz hastanın farklı eklemlerinde ve farklı derecelerde dejeneratif değişikliklerin geliştiği görüldü.

Çıkarımlar: İhmal edilmiş idyopatik çarpık ayak deformitelerinde tek seansta uygulanan posteromedial gevşetme ile birlikte üçlü artrodezin fonksiyonel ve kozmetik sonuç elde etmede etkili bir yöntem olduğu görüşündeyiz.

 

Keywords

• İhmal edilmiş çarpık ayak; posteromedial gevşetme; üçlü artrodez.

Medium-term results of single-stage posteromedial release and triple arthrodesis in treatment of neglected clubfoot deformity in adults

Abstract

Objective: This study aimed to evaluate the implementation, in a single session, of both massive posteromedial release and triple arthrodesis for rigid neglected clubfoot deformities in adult patients, and its effects on clinical and radiological results.

Methods: The procedures were performed in one session on 15 feet of 11 patients [7 male, 4 female; mean age 26 (range: 15 to 50)]. Staples were used for fixation in all patients. For clinical assessment, the AOFAS (American Orthopaedic Foot and Ankle Society) ankle- hindfoot scale was used.

Anteroposterior/lateral side talocalcaneal and talus-1st metatarsal angles were used as radiographic parameters. The mean follow-up was 7.5 years (range: 6 to 11).

Results: The mean AOFAS score rose from a preoperative 39 (range: 15 to 52) to 88 (range: 76 to 94) in the final follow up (p<0.0001). Among the 15 feet, 9 were evaluated as excellent, 5 as good, and 1 as fair. Significant clinical improvement was obtained between preoperative and postoperative surgical periods (p<0.05). Significant improvements were observed in radiographic parameters (p<0.0001).

At final follow-up, radiographic values were within normal physiological limits. Average union time was 12.4 (range: 7 to 36) weeks. While pseudoarthrosis was not observed in any patients, delayed union developed in 2 cases, and talus avascular necrosis in 1. In the preoperative period, 5 patients had various degrees of degenerative changes. Nine patients developed degenerative changes in different joints and of different degrees.

Conclusion: The authors believe that massive soft tissue release and triple arthrodesis performed in a single session yields satisfactory results cosmetically and functionally in neglected clubfoot cases with severe deformities.

Keywords

• Neglected clubfoot
• posteromedial release
• triple arthrodesis

References

1. Nordin S, Aidura M, Razak S, Faisham W. Controversies in congenital clubfoot : literature review. Malays J Med Sci 2002;9:34–40.
2. Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: twenty-five and forty-four-year av- erage follow-up of the same patients. J Bone Joint Surg Am 1999;81:1391–402.
3. Cummings RJ, Lovell WW. Operative treatment of congenital idiopathic club foot. J Bone Joint Surg Am 1988;70:1108–12.
4. Penny JN. The neglected clubfoot. Techniques in ortho- paedics 2005;20:153–66.
5. Ramseier LE, Schoeniger R, Vienne P, Espinosa N. Treat- ment of late recurring idiopathic clubfoot deformity in adults. Acta Orthop Belg 2007;73:641–7.
6. de Heus JA, Marti RK, Besselaar PP, Albers GH. The in- fluence of subtalar and triple arthrodesis on the tibiotalar joint. A long-term follow-up study. J Bone Joint Surg Br 1997;79:644–7.
7. Vanderwilde R, Staheli LT, Chew DE, Malagon V. Mea- surements on radiographs of the foot in normal infants and children. J Bone Joint Surg Am 1988;70:407–15.
8. Mäenpää H, Lehto MU, Belt EA. What went wrong in tri- ple arthrodesis? An analysis of failures in 21 patients. Clin Orthop Relat Res 2001;391:218–23.

9. de Groot IB, Reijman M, Luning HA, Verhaar JA. Long-term results after a triple arthrodesis of the hind- foot: function and satisfaction in 36 patients. Int Orthop 2008;32:237–41.
10. Turco VJ. Surgical correction of the resistant club foot. One-stage posteromedial release with internal fixation: a preliminary report. J Bone Joint Surg Am 1971;53:477– 97.
11. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myer- son MS, Sanders M. Clinical rating systems for the ankle- hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–53.
12. Herold HZ, Torok G. Surgical correction of neglected club foot in the older child and adult. J Bone Joint Surg Am 1973;55:1385–95.
13. van Dijk CN, Lim LS, Poortman A, Strübbe EH, Marti RK. Degenerative joint disease in female ballet dancers. Am J Sports Med 1995;23:295–300.
14. Evans D. Relapsed club foot. J Bone Joint Surg 1961;43- B:722–33.
15. Abrams RC. Relapsed club foot. The early results of an evaluation of Dillwyn Evans’ operation. J Bone Joint Surg Am 1969;51:270–82.
16. Lichtblau S. A medial and lateral release operation for club foot. A preliminary report. J Bone Joint Surg Am 1973;55:1377–84.
17. Toohey JS, Campbell P. Distal calcaneal osteotomy in resistant talipes equinovarus. Clin Orthop Relat Res 1985;197:224–30.
18. Dwyer FC. The treatment of relapsed club foot by the in- sertion of a wedge into the calcaneus. J Bone Joint Surg 1963;45-B:67–75.
19. Hersh A, Fuchs LA. Treatment of the uncorrected clubfoot by triple arthrodesis. Orthop Clin North Am 1973;4:103– 16.
20. Angus PD, Cowell HR. Triple arthrodesis. A critical long- term review. J Bone Joint Surg Br 1986;68:260–5.
21. el–Tayeby HM. The neglected clubfoot: a salvage proce- dure. J Foot Ankle Surg 1998;37:501–9.
22. Ahmed AEO. Two stages of surgery for treatment of per- sistent or untreated congenital Talipes Equinovarus in young adult. Pan Arab J Orth Traum 1999;3:51–7.
23. Dobbs MB, Nunley R, Schoenecker PL. Long-term fol- low-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am 2006;88:986–96.
24. Duncan JW, Lovell WW. Hoke triple arthrodesis. J Bone Joint Surg Am 1978;60:795–8.
25. Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Br 1987;69:593–7.
26. Doğan A, Albayrak M, Uğur F, Zorer G. Triple arthrodesis in rigid foot deformities and the effect of internal fixation on clinical and radiographic results. [Article in Turkish] Acta Orthop Traumatol Turc 2006;40:220–7.
27. Chow S, Brandser E. Diagnostic and Therapeutic Foot and Ankle Injections. Semin Musculoskelet Radiol 1998;2:421–432.
28. Pell RF 4th, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am 2000;82:47–57.
29. Wülker N, Flamme C. Hindfoot arthrodesis. [Article in German] Orthopade 1996;25:177–86. [Abstract]
30. Bednarz PA, Monroe MT, Manoli A 2nd. Triple arthrod- esis in adults using rigid internal fixation: an assessment of outcome. Foot Ankle Int 1999;20:356–63.
31. Graves SC, Mann RA, Graves KO. Triple arthrodesis in older adults. Results after long-term follow-up. J Bone Joint Surg Am 1993;75:355–62.
32. Hudson I, Catterall A. Posterolateral release for resistant club foot. J Bone Joint Surg Br 1994;76:281–4.
33. Yadav SS. Observations on operative management of ne- glected club-foot. Int Orthop 1981;5:189–92.
34. Haddad SL, Myerson MS, Pell RF 4th, Schon LC. Clini- cal and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 1997;18:489–99.
35. Yalçin S, Kocaoğlu B, Berker N, Erol B. Talectomy for the treatment of neglected pes equinovarus deformity in pa- tients with neuromuscular involvement. [Article in Turk- ish] Acta Orthop Traumatol Turc 2005;39:316–21.